Cardiovascular

PA Criteria: Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

• documented inadequate response to two Tier 1 medications, or
• adverse drug reaction to all the Tier 1 medications, or
• previous stabilization on the Tier 2 medication, or
• a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 1

• quinapril (Accupril®)
• ramipril (Altace®)
• captopril (Capoten®)
• benazepril (Lotensin®)
• trandolapril (Mavik®)
• fosinopril (Monopril®)
•  lisinopril (Prinivil®, Zestril®)
• moexipril (Univasc®)
• enalapril (Vasotec®)    

• perindopril erbumine (Aceon®)  

Tier 1

• quinapril (Accupril®)
• captopril (Capoten®)
• benazepril (Lotensin®)
• fosinopril (Monopril®)
• lisinopril (Prinivil®, Zestril®)
• moexipril (Univasc®)
• enalapril (Vasotec®)    

Tier 1

• amlodipine (Norvasc®)
• diltiazem (Cardizem®)
• diltiazem (Tiazac®, Taztia® XT)
• diltiazem CD (Cardizem® CD)
• diltiazem ER (Cartia® XT, Diltia® XT)
• diltiazem SR (Cardizem® SR)
• diltiazem XR (Dilacor® XR)
• felodipine (Plendil®)
• isradipine (Dynacirc®, Dynacirc® CR)
• nicardipine (Cardene®)
• nifedipine (Adalat®, Procardia®)
• nifedipine CC (Adalat® CC)
• nifedipine ER nifedipine XL (Nifedical® XL, Procardia® XL)
• nimodipine (Nimotop®)
• verapamil (Calan®, Isoptin®, Verelan®)
• verapamil SR (Calan® SR, Isoptin® SR, Verelan® PM)

• amlodipine/atorvastatin (Caduet®)
• diltiazem (Cardizem® LA)
• diltiazem ER (Matzim® LA)
• nicardipine (Cardene® SR)
• nisoldipine (Sular®)
• verapamil (Covera® HS)

Tier 1

• Tier 1 ACE + Tier 1 CCB  

• enalapril/felodipine (Lexxel®)
• benazepril/amlodipine (Lotrel®)
• trandolapril/verapamil (Tarka®)

Tier 1

• benazepril (Lotensin®)
• captopril (Capoten®)
• enalapril (Vasotec®)
• fosinopril (Monopril®)
• lisinopril (Prinivil®, Zestril®)
• losartan (Cozaar®)
• losartan/HCTZ (Hyzaar®)
• moexipril (Univasc®)
• quinapril (Accupril®)
• ramipril (Altace®)
• trandolapril (Mavik®)  

• amlodopine/valsartan (Exforge®)
• amlodopine/valsartan/HCTZ (Exforge® HCT)
• amlodipine/olmesartan (Azor®)
• azilsartan/chlorthalidone (Edarbyclor®)
• azilsartan (Edarbi®)
• olmesartan (Benicar®)
• olmesartan/HCTZ (Benicar® HCT)
• olmesarten med/amlodipine/HCTZ (Tribenzor®)
• valsartan (Diovan®)
• valsartan/HCTZ (Diovan® HCT)

• candesartan (Atacand®)
• candesartan/HCTZ (Atacand® HCT)
• eprosartan (Teveten®) eprosartan/HCTZ (Teveten® HCT)
• irbesartan (Avapro®) irbesartan/HCTZ (Avalide®)
• telmisartan (Micardis®)
• telmisartan/amlodipine (Twynsta®)
• telmisartan/KHCTZ (Micardis® HCT)  

Tier 3 authorization requires:

• FDA approved indication
• Recent trial, within the previous 6 months and at least 4 weeks in duration, of an ACE Inhibitor (or an ARB if previous trial of an ACEI) and a diuretic, used concomitantly at recommended doses, that did not yield adequate blood pressure control.
• Clinical exceptions will be granted for members already currently on aliskiren and valsartan at the available doses of Valturna.
• Prior Authorization form
  

Tier 1

• Tier 1 ACE Inhibitor + Diuretic
  

• ARB + Diuretic
  

• aliskiren/amlodipine (Tekamlo®)
• aliskiren (Tekturna®)
• aliskiren/HCTZ (Tekturna® HCT)
• aliskiren/valsartan (Valturna®)

Consideration will be based on ALL of the following criteria:

PA criteria:

• An FDA approved diagnosis of moderately severe to severe essential hypertension or uncomplicated malignant hypertension; AND
• Use of at least 6 classes of medications, in the past 12 months, that did not yield adequate blood pressure control. Treatment must have included combination therapy with a diuretic, and therapy with at least a four-drug regimen. Medications can be from,  but not limited to, the following classes: ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), direct renin inhibitors (DRIs), beta blockers, alpha blockers, alpha agonists, diuretics, etc,; AND
• Prescriber must verify member does not have ANY of the following contraindications:  
  • Coronary insufficiency
  • Recent myocardial infarction
  • Rising or elevated BUN, or known renal insufficiency
  • Uremia
  • Glaucoma
  • Organic pyloric stenosis
  • Currently receiving sulfonamides or antibiotics
  • Known sensitivity to mecamylamine (Vecamyl™)   

PA Criteria:

Nexiclon® XR (clonidine extended release) and Catapres TTS Patch (clonidine transdermal patch) require prior authorization with the following criteria:

• FDA-approved indication of hypertension in adults.
• Must provide a clinically significant reason why the member cannot take clonidine immediate release tablets.
  

omega-3-acid ethyl esters (Lovaza®)/icosapent ethyl (Vascepa®)

PA Criteria:

• Laboratory documentation of severe hypertriglyceridemia (fasting triglycerides _500 mg/dL), and controlled diabetes (fasting glucose <150 mg/dL at the time of triglycerides measurement and HgA1C<7.5%), and
• Previous failure with both nicotinic acid and fibric acid medications.

PA Criteria:

Consideration will be based on all of the following criteria:

• An FDA approved diagnosis of homozygous familial hypercholesterolemia defined by the presence of at least one of the following criteria:
  • A documented functional mutation(s) in both LDL receptor alleles or alleles known to affect LDL receptor functionality via genetic testing; OR
  • An untreated total cholesterol >500 mg/dL and triglycerides <300 mg/dL AND at least one of the following:
    • Documentation that both parents have untreated total cholesterol >250 mg/dL; OR
    • Presence of tendinous / cutaneous xanthoma prior to age 10 years; AND
• Documented failure of high dose statin therapy (LDL reduction capability equivalent to atorvastatin 80mg or higher); AND
• Prescriber must be certified with Juxtapid™ or Kynamro™ REMS program.
• Prior Authorization form  

PA Criteria: Tier 1 products available with no authorization necessary

Tier 2 authorization requires:

• A trial with atorvastatin, consisting of at least 8 weeks of continuous therapy, titrated to 40mg, which did not yield adequate LDL reduction.  The minimum starting dose of the Tier 2 medication may only be at the moderate to high LDL lowering doses (20mg  rosuvastatin of higher), or
• Documented adverse effect or contraindication to all available lower tiered products, or
• Clinical exception for high risk members hospitalized for recent acute myocardial infarction or acute coronary syndrome for atorvastatin 40mg.
  

• atorvastatin (Lipitor®)
• lovastatin (Mevacor®)
• pravastatin (Pravachol®)
• simvastatin (Zocor®)

• rosuvastatin (Crestor®)  

• lovastatin/niacin (Advicor®)
• lovastatin (Altoprev®)
• fluvastatin (Lescol® Lescol®  XL)
• ezetimibe/atorvastatin (Liptruzet®)
• pitavastatin (Livalo®)
• simvastatin/niacin (Simcor®)
• simvastatin/ezetimibe (Vytorin®)
• ezetimibe (Zetia®)
• ezetimibe/atorvastatin (Liptruzet)

%LDL Reduction

PA Criteria:

Tier 1 products are available with no authorization necessary

Tier 2 authorization requires:

• Laboratory documented failure of a tier one medication after 6 months trial, or
• Documented adverse effect, drug interaction, or contraindication to tier 1 products.
• Prior Authorization form

• clofibrate (Atromid® - S)
• micronized fenofibrates (Lofibra®)
• gemfibrozil (Lopid®)
• micronized fenofibrates (Tricor®)
• fenofibrates (Trilipix®)
  

• micronized fenofibrates (Antara®)
• fenofibrate (Fenoglide®)
• micronized fenofibrates (Lipofen®)
• fenofibrates (Triglide®)
  

The first 90 days available with no authroization required for members new to therapy. After the first 90 days, the following criteria will apply.

• Therapy will be approved for members who are diagnosted with UA/NSTEMI and STEMI patients who are to be managed with percutaneous coronary intervention (PCI), primary or delayed.
• Length of approval will be for 1 year.
• Effient® will not be approved for members with the following situation:
  • CABG surgery
  • Members with a history of TIA or stroke
• Members greater than 75 years of age will generally not be approved without supporting information.
• Prior Authorization form
  

The first 90 days are available with no authorization necessary.

• Therapy will be approved for members are diagnostic with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PHI).
• Length of approval will be for 1 year.
• Prior Authorization form

• Approved for diagnosis of non-ST-Segment elevated ACUTE coronary syndrome or ST-Segment elevated ACUTE myocardial infarction.
• Approval will be for only one dose of 300mg.
• Prior Authorization form

• FDA approved diagnosis of pulmonary arterial hypertension.
• Medical supervision by a pulmonary specialist and/or cardiologist.
• Quantity limits:
  • tadalafil (Adcirca®) 20mg tabs: #60 tablets per 30 days.
  • sildenafil (Revatio®) 20mg tabs: #90 tablets per 30 days.
• Prior Authorization form

The first 90 days available with no authroization required for members new to therapy. After the first 90 days, the following criteria will apply.

• Therapy will be approved for members who are diagnosted with UA/NSTEMI and STEMI patients who are to be managed with percutaneous coronary intervention (PCI), primary or delayed.
• Length of approval will be for 1 year.
• Effient® will not be approved for members with the following situation:
  • CABG surgery
  • Members with a history of TIA or stroke
• Members greater than 75 years of age will generally not be approved without supporting information.
• Prior Authorization form
  

The first 90 days are available with no authorization necessary.

• Therapy will be approved for members are diagnostic with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PHI).
• Length of approval will be for 1 year.
• Prior Authorization form

• Approved for diagnosis of non-ST-Segment elevated ACUTE coronary syndrome or ST-Segment elevated ACUTE myocardial infarction.
• Approval will be for only one dose of 300mg.
• Prior Authorization form

• FDA approved diagnosis of pulmonary arterial hypertension.
• Medical supervision by a pulmonary specialist and/or cardiologist.
• Quantity limits:
  • tadalafil (Adcirca®) 20mg tabs: #60 tablets per 30 days.
  • sildenafil (Revatio®) 20mg tabs: #90 tablets per 30 days.
• Prior Authorization form

• Approval will be for FDA approved indication.
• Special consideration will be given for a diagnosis of DVT when warfarin is not a viable option.
• Prior Authorization form

• Xarelto® 10mg: One prescription for up to 35 days of therapy is allowed without prior authorization every 6 months.
• Xarelto® 15mg and 20mg: diagnosis of non valvular atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), or to reduce the risk of recurrent DVT and PE will be required.
• Eliquis® diagnosis of nonvalvular atrial fibrillation will be required.
  
• Prior Authorization form

• Approval will be for FDA approved indication.
• Special consideration will be given for a diagnosis of DVT when warfarin is not a viable option.
• Prior Authorization form

• Documented diagnosis of HAE
• Only for acute attacks of HAE

PA Forms

• Prior Authorization form
• Physician/Outpatient Administered